3D Airway Analysis in OSA and TMD Therapy

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Ralf Johnston
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1 3D Airway Analysis in OSA and TMD Therapy

2 Gy Yatros, D.M.D. Diplomate ABDSM Faculty USF Co-Founder of Dental Sleep Solutions Co-Founder DS3 Dental Sleep Software 2

3 Airway: Role of imaging Airway Imaging Can Not Confirm or Exclude OSA Imaging Can Help Understand Airway Anatomy (Phenotype) Identify Potential Obstruction Sites Evaluate Airway Support Structures

4 How I got involved in CBCT 4

5 The Dose Story in perspective 5

6 RADIATION EXPOSURE IN DAILY LIFE Average annual effective dose in the US is 3,000 µsv* This is approximately 8 µsv/day *White and Pharoah: Oral Radiology Principles and Interpretation 6 th ed.

7 AIR TRAVEL Estimated air travel for a 8 hour flight results in 80 to100 µsv exposure

8 AUTOMATIC DOSE CONTROL (ADC)

9 OP300 MAXIO LDT EFFECTIVE DOSE COMPARED TO 2D EFFECTIVE DOSE (* Patient doses from Dental X-Ray Exams (Ludlow et al. 2008) (** OP300 Maxio Dose Study (Ludlow 2014) 9

10 OP300 MAXIO LDT EFFECTIVE DOSE COMPARED TO 2D EFFECTIVE DOSE (* Patient doses from Dental X-Ray Exams (Ludlow et al. 2008) (** OP300 Maxio Dose Study (Ludlow 2014) 10

11 Why 3D? 11

12 3D imaging adds value to your treatment 12

13 Practice building and differentiation 13

14 How do patients perceive a practice? 14

19 Using 3D in the Dental office Treatment planning and diagnosis Office efficiency Endo 3 rd molar evaluation Ortho 19

20 Screening & Patient Education Patient Candidacy & predicting factors - Anatomy, other treatment options, etc. TMJ Baseline and Diagnostics Nasal Airway MAD Jaw positon? CBCT Game Changer 20

21 13x15 CM FOV Fields of View Orthognathics Airway TMJ Nasal Airway Trauma 21

22 OP300 Maxio Confident diagnostics for entire maxillofacial region OP300 Maxio 8x15 OP300 Maxio 13x15 The perfect FOV for all of todays and any future needs 22

23 CBCT Game Changer Screening & Patient Education 23

24 Airway Evaluation 24

25 Airway Evaluation 25

26 Minimal Cross-Sectional Area Probability of OSA *Avrahami E, Englender M. Relation between CTaxial cross-sectional area of the oropharynx and obstructive sleep apnea syndrome in adults. AJNR Am J Neuroradiol 1995;16(1):

27 Airway Evaluation 27

28 Airway Evaluation 28

29 Airway Evaluation 29

30 Airway Evaluation 30

31 Airway Evaluation 31

32 Airway Evaluation 32

33 Screening & Patient Education Patient Candidacy & predicting factors - Anatomy, other treatment options, etc. TMJ Baseline and Diagnostics Nasal Airway Jaw Position? CBCT Game Changer 33

34 Pharyngeal Tonsil (Adenoids) 34

35 Nasal Anatomy 35

36 Normal Nasal Anatomy 36

37 Nasal Deviation 37

38 Nasal Deviation Guess Who? 38

39 Nasal Deviation 39

40 CBCT TMJ Considerations 40

41 TMJ Evaluation 41

42 Condylar Head & Fossa Changes 42

43 Patient Case 1 43

44 Patient Case 44

45 Patient Case 45

46 Patient Case 46

47 Patient Case 47

48 Airway Analysis AIRWAY: -The soft palate was approximately 48 mm long. - Nasal septum deviation and small concha bullosa of the right and left middle nasal turbinates was noted. -The most constricted area of the airways corresponded to the area posterior to the tongue and soft palate and it is reduced (approximately 70 mm2). This space is small and should be considered an intermediate risk factor for obstructive sleep apnea (OSA). 48

49 Sinus Evaluation 49

50 Sinus Evaluation Signs of increase in the mucosal thickening were noted from the floor of the maxillary sinuses and from selected ethmoidal air cells. This is consistent with allergies or another condition of inflammatory origin (sinusitis). The antromeatal complexes were patent/clear. - Dome-shaped soft tissue densities were noted from the floor of the maxillary sinuses and sphenoid sinus. They are consistent with mucous retention cysts/sinus polyposis. - A soft tissue density was noted from the superior-anterior wall of the left maxillary sinus. This is consistent with a sinus polyp. 50

51 TMJ Evaluation 51

52 TMJ Evaluation 52

53 TMJ Evaluation 53

54 TMJ Evaluation Left Evidence of mild sclerosis and flattening for the superior/posterior surface of the left condyle and sclerosis for the posterior slope of the left eminence was noted. 54

55 TMJ Evaluation Right The right condyle was small. The reduction in size occurred along the posterior and superior surface of the right condyle (anterior-posterior and vertical dimension). Evidence of sclerosis, flattening and small osteophyte formation for the superior/anterior surface of the right condyle and mild sclerosis for the posterior slope of the right eminence was noted. 55

56 TMJ Evaluation Position: When the mandible was in closed position the right condyle was positioned posterior to the center and the left condyle close to the center of their respective fossa. The right posterior articular spaces were reduced. OTHERS: - Bilateral elongation/partial calcification was noted for the styloid-hyoid ligament/process. 56

57 Radiologist Impressions Airways The findings described above should be considered risk factors for obstructive sleep apnea (OSA). 57

58 Radiologist Impressions TMJs The findings described above are most consistent with NON-ACTIVE degenerative joint disease (DJD) for the right TMJ and osseous remodeling for the left TMJ. DJD involves the destruction of the articular tissues and may occur when the remodeling capacity of those tissues has been exceeded by the functional demands. The presence of these changes increases the probability of a displaced disc in the right TMJs. Reduction of condylar size maybe associated with changes in occlusion, asymmetries and mandibular posture which may predispose to TMJ dysfunction. The posterior positioned condyles within their fossa may predispose to anterior displaced discs and compression of the posterior surface of the condyles and the adjacent retrodiscal tissues. 58

59 Radiologist Impressions Most of the other findings and their correspondent diagnosis were noted above. Please correlate the sections with the axial and panoramic views for additional diagnosis and treatment planning purposes. Reviewing the remaining available volume, there was no evidence of any other anomaly/pathology in the maxillofacial and surrounding structures available in this study. 59

60 Case 1 60

61 So what did we learn? Patient has small airway and is at risk for OSA Nasal airway is compromised. Pt. may have allergies and has sinus abnormalities. TMJ s have existing abnormalities. Teeth are adequate support for Dental Sleep Therapy (DST). 61

Advise patient they are at risk for OSA.

CPAP and/or Dental Sleep Therapy (DST) due to nasal problems.

Advise patient they have existing TMJ concerns and they are

62 Advise patient they are at risk for OSA. Advise patient they have increased risks of problems with CPAP and/or Dental Sleep Therapy (DST) due to nasal problems. Advise patient should consider ENT and/or allergist referral. Advise patient they have existing TMJ concerns and they are at higher risks of complications with DST. RB&A of Treatment and informed consent! 62

63 63

64 64

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66 Case 2 86 Events/Hr.! 66

67 Case 2 Subjective 67

68 Case 2 Objective 68

69 Case 2 Pre-Treatment 69

70 Case 2 Post-Treatment 70

71 Case 2 Pre-Treatment Post-Treatment 71

72 CBCT Sleep Medical Insurance billing 72

73 CBCT Billing Key Points Documentation Preauthorization Accreditation 73

74 CBCT Documentation Documenting Medical Necessity is KEY!! 74

75 CBCT Documentation You need to know what questions to ask to gather information specific to the necessity for a CBCT to bill to insurance. History of head or neck trauma Recurrent sinus infections or history of sinus problems History of head or neck surgery Nasal obstruction Problems swallowing TMD signs/symptoms or history of TMD 75

76 CBCT Preauthorization All Pre-Authorization Include a medical necessity statement as to why a CBCT is standard of care for the treatment we provide as well as specific clinical information related to the patient that would support the need for the CBCT. CPT: Maxillofacial sinus CT without contrast Modifier: TC (technical component) We are not billing for interpretation. Must have ICD-10 diagnosis code (OSA G47.33) 76

77 CBCT Accreditation Intersocietal Accreditation Commission Dental Website Requirement of being accredited to receive payment from Medicare as well as many private insurance companies when billing CT scans. 77

Dr. Gy Yatros D.M.D. info@dentalsleepsolutions.

78 Dr. Gy Yatros D.M.D SNORE

The future of health is digital

The future of health is digital Dated: XX/XX/XXXX Name: XXXXXXXX XXXXXXXXXXX Birth Date: XX/XX/XXXX Date of scan: XX/XX/XXXX Examination of the anatomical volume: The following structures are reviewed and evaluated for bilateral symmetry,